Empowering Nurses to Change Public Policy

At the Core of Care

Published: October 5, 2020

SARAH: This is At the Core of Care. A podcast where people share their stories about nurses and their creative efforts to better meet the health AND health-care needs of patients, families and communities.

I’m Sarah Hexem Hubbard, executive director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium.

On this episode, we’re taking up the issue of civic engagement and how nurses can play a role in shaping public policy within the communities they serve. And to illustrate these points, we’re going to hear about a longstanding effort in Philadelphia to require lead testing and remediation in rental properties. The result was the Philadelphia City Council passing a new law that’s just now starting to take effect as of October 2020.

We’re going to hear first from my colleague Erin Blair of the National Nurse-Led Care Consortium. Erin is a home visiting nurse in Philadelphia and has seen firsthand the negative effects of lead exposure on children. She’s been an advocate around this issue as we’ll hear and coordinated with families affected by lead exposure to publicly share their experiences.

ERIN: We really built a policy agenda that was based on our clients’ concerns as much as possible and elevating our client voice in the advocacy work that we were doing and housing conditions are something that just about every family that I work with is interested in talking about. They want safe homes for their babies. Nobody wants to poison their children.

SARAH: After Erin, we’ll hear from Colleen McCauley. She’s the health policy director for PCCY, or Public Citizens for Children & Youth, and helped shape the new lead legislation in Philadelphia. Colleen has a nursing and public health background and has spent much of her career pushing for stronger policies to help mitigate and eradicate lead poisoning.

COLLEEN: I work on lead poisoning because of the long term impact it has on babies and children. We do the work because we know how to prevent it. It's not rocket science. Right. We know the source of lead and it's about removing kids' exposure to it. And in Philadelphia, in Pennsylvania, and across the country, the number one way that babies are poisoned is lead-based paint dust.

SARAH: And at the end, Katie Huffling will share her perspective with us on how nurses can help create systemic change around various environmental health issues. Katie is the executive director for the Alliance of Nurses for Healthy Environments.

KATIE: Nurses, we're the most trusted profession for almost 20 years. Every year when the Gallup poll looks at what the most who the most trusted profession is. Nurses are always number one. And so I think there's a real opportunity for nurses to use that professional standing to help lead change. We do a lot of work with nurses in the policy realm. Talking with policymakers, with their Congress, people, talking with the EPA, providing testimony and talking about. The link between health and the environment, and we can speak with such eloquence and, you know, really lovely mix of personal stories and the science. And so I think nurses have such a strong voice.

ERIN: My name is Erin Blair. I am a nurse, home visitor with the Philadelphia Nurse-Family Partnership, and the policy and advocacy nurse liaison for HELP MLP-Nursing Legal Partnership.

When the nursing legal partnership came to Philadelphia, we had a nurse liaison position that was really focused on getting the communication between the nurses and the legal team. And I always saw that position as an opportunity for a policy and advocacy position. Right. So someone to translate the needs of nurses into policy and advocacy action that we could take into the community, that we could shop around to legislators, where we could really support families.

Back when I joined Nurse-Family Partnership in 2008, there was an amazing program called Lead Safe Babies in the city of Philadelphia where anyone who is pregnant or with a child under six years of age was able to access lead teaching and prevention, and often to access some funding to be able to repair any lead that was found present in the home. I would call during pregnancy, they'd come out and do some lead swipes. And if lead was identified, we would talk about remediation options for family-owned homes or we would work with landlords to get them to remediate any lead issues that were discovered. Unfortunately, after 2008, we had a bit of a recession and there was a lot of funding that was removed from our pretty extensive lead work in Philadelphia. And the loss of that was really where my interests got piqued in participating in a greater lead advocacy work. First off, to help legislators understand the issue is really hard to watch children get poisoned over and over and over again. And prevention really is the only and best way to manage the lead issues in the Philadelphia area. Currently when a lead issue is identified, if a child is under 10 micrograms per milliliter lead, they are not eligible for remediation services or assistance other than education.

Philadelphia has very, very old housing stock. And so most of the homes of the families I'm working with are built before 1978, before 1980. And there's no guarantee that there wasn't still lead paint hanging around after 1978 and that people weren't using old paint to bait their homes. But that is when the law passed that lead paint was no longer allowed to be used in home construction and painting and such things. So when I come into a home, even though the interior of the home may have been made lead safe, the exterior of the home is also a risk. So if there's a lot of chipping and peeling paint on awnings, on buildings nearby, you can pretty much bet that anyone that walks in that front door is bringing some lead with them on their shoes in the form of lead dust. And then when you get to crawling age, you've got babies on the floor crawling around, picking up everything on their hands and constantly putting their hands in their mouths.

I talk a lot with families about potential side effects of lead exposure and lead poisoning are. So that they have a broader understanding that it’s not just a result you get in a blood test and you can’t change in your child. It’s trying to help them understand how lead takes up residence in the body. Once lead gets in, it’s very hard to get out. And so prevention really is the key because there is no safe level of lead. Any lead can lead to long-term complications for children and their physical development, their psychological development, their learning, their behavioral development. It can also affect pregnancy and the developing fetus. And that's really challenging because as a home visitor, when I'm in a home and I see the lead and I teach the families how to best prevent it and the child still getting exposure. And unfortunately, that number of lead tests family receive is not adequate. And the continued monitoring of lead-exposed children is often confusing to their families and may not happen at all if the family is switching providers regularly, which our families often do.

I've been on board talking with legislators about housing conditions and housing issues for a very long time and lead is one of those issues. And so I was able to testify. The nursing legal partnership collected a lot of testimony from various families that had been affected by led and submitted those testimonies for the hearings, as well as having myself, another nurse testify. And we also were able to have a family that I worked with testified regarding her experience with housing and lead laws. There’s the emotional and human cost, which I think in that we are able to talk about the experience of a family getting a diagnosis and watching their child lose milestones that they previously had. When you have a toddler, that's a cheerful, happy, rambunctious bundle of energy and you watch them slow down, you watch their language acquisition go backward so that they're no longer using the big words they were using before starting to learn sentences. You see them starting to just tug on a parent's clothes, point, grunt, not communicate fully their needs and their emotions, which oftentimes ends up with them communicating their emotional needs through behaviors that are very confusing and challenging for a parent to deal with. And so as a home visitor, when we're working with families, with children, with significant developmental and social-emotional delays, we're then pulling in early intervention services. But we're just seeing that parent kind of mourn that loss potential that they had already seen in their child and learn a new child that needs these different additional supports. It's really, really hard. And it's especially frustrating because it's preventable.

COLLEEN: I'm Colleen McCauley and I'm the health policy director at Public Citizen's for Children and Youth, or PCCY. I've been at PCCY for 19 years and was hired to come on board to do advocacy and policy work on lead poisoning. That's initially the grant I was hired on. And PCCY had been working on lead poisoning, you know, already at that point for, you know, probably five, 10 years. So PCCY was the leading voice in the city on lead poisoning prevention for babies.

We started working probably back in 2008 or so on the original Philadelphia lead certification law. There was acknowledgment at that time, a significant number of those babies poisoned in rental properties. And, you know, you're not supposed to be able to rent a property that has a toxic hazard like lead in it. So, you know, back, like I said, about 12 years or so ago, we started working on an ordinance.

So we formed a coalition. We created a language for the lead certification law. And the original lead certification law that got passed in Philadelphia required landlords with older properties built before 1978 when lead was banned for use in residential paint. Landlords with pre-1978 units with children six and under were required to dust wipe, test their property, and secure a lead-safe or lead-free certification. So they just essentially they're showing that their property does not have toxic lead hazards in it. We asked for the law to apply universally to all older properties. But in the 11th hour, before the law got passed, it only applied to properties with children six and under. And it also was required when a family entered a new lease. And the problem is that there is no record of the ages of tenants on your lease. So as the city trying to enforce this ordinance, they don't know where these children live. So how would they know which landlords the law applies to? So the greatest shortcoming of the original law was that it wasn't universal, didn't apply to all older properties. And at the same time, there was of concern right as it was passed, that it would be discriminatory under the Fair Housing Act because we thought that there would likely be some landlords. Perhaps a small portion, but some landlords who might refuse to rent properties to pregnant women or families with small children because they did not want to have to comply with the law. And we didn’t know largely who was complying and who wasn’t and there were few penalties issued for landlords who did not comply.

Over time, we continued to see the majority of children being poisoned in rental properties. 62 percent of children in Philadelphia poisoned by lead was poisoned by rental properties. I believe, early, 2018, we were able to confirm that because of what we did. Because the greatest impetus for us to go forward and try to modify and strengthen the existing certification law was the tragedy in Flint, Michigan. The poisoning of children in Flint, Michigan, the poisoning of children in Flint Michigan put lead poisoning back on the map for the country. It was difficult for us prior to Flint to get traction among policymakers and the public. And again tragically in Flint Michigan, those children were poisoned by a corrupt water source. In Philadelphia, the main source of poisoning is lead-based paint dust in children’s older homes. And so we started in earnest a fresh campaign to strengthen the existing lead certification law. And we had several nursing groups participate in the coalition that we formed, the Lead-free Philly Coalition, to modify the existing lead law. The Nurse-Family Partnership. The National Nurse-Led Care Consortium. The Family Practice and Counseling Network. It's a network of primary care centers that are run by nurse practitioners. I used to work at the Family Practice and Counseling Network myself as one of my first jobs out of nursing school.

Philadelphia's passed the most protective lead law for children in the country, essentially. And so the law requires landlords of nearly all pre-1978 properties in Philadelphia to comply with the law. Landlords have to secure a lead-safe or lead-free free certification every four years in order for a landlord to secure an annual rental license renewal. They have to have a certification on file with the health department. Again, that's verifying that there are no lead hazards in their rental property. So it is the law, this is essentially requiring landlords to show that there are no toxic lead hazards in their property. Regardless of how old the kids are in the property. So there's a three year transition period for all units in Philadelphia to start trying again. Come October 1st, there's a three year transition period for all units to come into compliance, starting with the highest risk, the zip codes. So starting October 1st, 2020, the 11 zip codes that have the highest share of kids poisoned will have to comply with tests, you know, with every unit being tested. And then in the second, starting in 2021, the next set of zip codes will be added and in 2022, the last set of zip codes will be added and then all landlords in the city will be complying.

This was a huge team effort and I mean a significant team effort. So having nurses involved and doctors and parents for sure. But it's also painters, lead inspectors, lead mediators, public interest law, organization, landlords, environmental groups, health plan, hospitals, housing groups, community development corporations. This very large group of advocates with a single focus. So Erin and the nurses. They helped in every aspect. They talked to reporters. They identified parents and and and supported parents to tell their stories to the paper, to our policymakers. They showed up at community events to raise public awareness about the impact of lead poisoning and that and the significance of strengthening Philadelphia's law. They made visits to our council members, our policymakers. Nurses were integrally involved in all aspects of this campaign, along with many of the stakeholders I also mentioned.

I work on lead poisoning because of the long term impact it has on babies and children. We do the work because we know how to prevent it. It's not rocket science. Right. We know the source of lead and it's about removing kids' exposure to it. And in Philadelphia, in Pennsylvania, and across the country, the number one way that babies are poisoned is lead-based paint dust. So we do it because we know what the answer is. Get it out of kids' houses. We do it because it's it disproportionately impacts black and brown babies. This is a racial justice issue. It also tends to impact children being raised by single women. So this is a women's issue. It's an economic justice issue. And that those are some of the large reasons why we work on this.

KATIE: My name is Katie Huffling and I'm the executive director of the Alliance of Nurses for Healthy Environments. I'm also a nurse-midwife.

We're the only national nursing organization focused on the intersection of health and the environment. And we work with nurses around the country on a variety of environmental health issues.

I became involved with the alliance after working as a nurse-midwife for several years, I became aware of how exquisitely sensitive the growing fetus is to environmental exposures and how many of the chronic diseases that we're currently facing in this country. Things like obesity, diabetes, other chronic diseases that we're seeing rising rates of have a significant environmental component to them. And so the more I started investigating environmental exposures, the more I felt called to work in that space and to help moms and babies have healthier pregnancies, have a better start in life. And then from there, I got the awesome opportunity to work full time in this space as the director of the Alliance of Nurses for Healthy Environments. And it's been a dream job. It's amazing.

I think I work in the environmental health space is just a really natural fit for nurses. Our nursing training helps us to see the health of our patients and communities in a very holistic manner. We understand that where a person lives, works, and plays can really impact their health. And so in my job, one of the things that I think we excel at is educating nurses on the issues. And as soon as I talk to nurses about environmental exposures, they quickly get it. They're like, oh, I know I can make that leap from, you know, how exposure can impact a child's risk for asthma or, you know, in the case of lead contamination that, you know, the issues that we're seeing with neurodevelopment and then, you know, nurses are really fix-it people. And so when they see these issues, they really want to investigate ways that they can help support making change.

It's really amazing to watch nurses dip their toes into the policy water and really start working in that space. I think some nursing programs, especially in their community and public health courses, which if you're in a baccalaureate nursing program, is required class in some of those. They're really making a nice emphasis on that and in trying to show those nursing students how much power they can have and being involved in the policy realm. But I definitely think that it's an area where we could expand that. It really should be part of all nursing programs and nursing students given an opportunity to speak with policymakers. You know, I've been with lots of nurses the first time that they are talking to a policymaker and they can be a little intimidating at first. And it's just really wonderful to watch them change and to see how much more confidence they get. After speaking with one or two people, they start to realize, you know, we are experts in health, we're experts in nursing.

One of the most important ways that nurses can assess for issues in the home environment or identify issues is through programs like the Nurse-Family Partnership. In some states, they have things like healthy start where at-risk women are identified during pregnancy and there they then have access to home health nurses that come in, do a really robust assessment in the home, and help to provide support during their pregnancy and for early childhood or that new infant on to really help them get the best start in life. So I think having nurses in the home is important in helping reduce those exposures. So actually, my organization has identified that this as a huge need in communities throughout the country. And so we actually just finished our first cohort of the Alliance of Nurses for Healthy Environments, Environmental Health Nurse Fellowship Program. And this was a yearlong fellowship with 30 nurses from around the country. We had three in each EPA region. And those three fellows in each region were matched with a mentor. And we had education throughout the year.

A core part of nursing education is that as a nurse, you're an advocate for your patient. And so if you're taking care of a patient in the hospital, you're advocating for them to make sure that they get the best care possible. And I think of political advocacy as just an extension of that. And if we look at our community as our patient, even our individual patients, by becoming engaged in political advocacy, talking with policymakers, we're advocating for our patients. It's just a little bit different fashion. It’s, I think, just such a natural extension of nursing practice. You know, I would just encourage nurses listening to this. If you haven't become involved in advocacy, please get involved. You know, even just calling your local councilperson. If there's an issue in your town and always tell them that you're a nurse and calling because that does make a difference. You know, they'll listen to you as a trusted voice. As part of our nursing education, we're taught how to take complex health and science information and presented in a way that's understandable by the general public. And so, you know, I think we're really able to make a nice bridge between the science and general information that we can give to the public and to policymakers because they're not experts on this information and when we're able to translate that for them, I think it's really powerful.


SARAH: Special thanks to Erin Blair, Colleen McCauley, and Katie Huffling for taking time to talk with us.

For more about the PA Action Coalition and our current outreach efforts, visit us online at paactioncoalition.org. And you can always follow us on social media @PAAction.

Funding for this podcast comes from the Center to Champion Nursing in America, which is a joint initiative of the Robert Wood Johnson Foundation, AARP, and the AARP Foundation...along with the Pennsylvania Action Coalition.

Stephanie Marudas of Kouvenda Media is our producer and we had production assistance from Brad Linder.

I’m Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.